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Problems Following Colostomy and Ileostomy
Problems Following Colostomy and Ileostomy B. MARDEN BLACK, M.D.
COLONIC STOMA
Complications
The complications occurring immediately after the formation of a colonic stoma include infarction and sloughing of the end of the colon, prolapse of a loop of small bowel beside the colon, formation of fistulas, and retraction of the end of the colon. Major surgical complications arc unusual and should be preventable; when they do occur, however, immediate surgical treatment is necessary. Extensive sloughing of the end of the colon is particularly unfortunate, since usually a new and far less satisfactory loop colonic stoma must be established. Subcutaneous infections at the site of the stoma are rather common. Ordinarily healing occurs, with time, unless a fistula develops. Practically the only complications of a long-established colonic stoma are prolapse of the bowel, stricturing at the junction of skin and mucosa, and formation of hernias at the site of the stoma. The three complications tend to occur together. The opening in the skin becomes progressively smaller until the bowel cannot empty satisfactorily, the bowel beyond the fasciallayer elongates, and a hernia-which can be large or small-develops. The complications arc not preventable and recurrences eventuate also, though usually only after many months or years. Ultimately, surgical treatment may become necessary, but it is relatively simple. In the procedure of "plastic enlargement of the stoma" or "revision of the colostomy," the opening in the skin is enlarged, the redundant bowel is excised, the hernial sac is removed, and the peritoneum is reclosed snugly around the bowel. Although the surgical procedure presents no problems, infection of the surrounding tissues develops commonly, often requiring a hospital stay out of all proportion to the magnitude of the procedure. Slight bleeding from the exposed mucosa resulting from irritation by the dressings is not uncommon. The bleeding usually stops promptly after a change in the type of dressings or in the tightness of the belt. The possibility of a carcinoma or a polyp should be considered if the
993
994
R.
MARDEN BLACK
bleeding does not stop, or if it seems to originate above the exposed mucosa. Routine Management
The management of a permanent colonic stoma is quite simple in principle. The purpose of the program is to achieve a firm, formed stool that is evacuated at the same time each day. To this end, foods that have a laxative effect such as fruits and vegetables are eaten moderately and excessive intake of fluid is avoided. To provide the desired regularity, the intake of food and fluids is kept as constant as possible in both time and amount. As a rule the establishment of a suitable routine requires several months. Some regularity should begin to appear within a few weeks; and at about the same time, the stools should begin to become formed. Continued looseness of the bowels results most commonly from an excessive intake of liquids, and less often from excessive amounts of fruits and vegetables. Occasional looseness usually may be traced easily to some obvious change in the dietary. When firmness of the stool has been achieved, some experimentation with different foods and with the amounts of food should be encouraged. The common tendency, particularly of elderly persons, to limit the diet unduly should be guarded against. I prefer not to begin irrigations until after some control has been achieved by dietary measures alone. Irrigations are something of a nuisance; and many persons who are able to remain at home, such as housewives and retired individuals, may be able to manage without their use. Irrigations are usually advisable in the case of persons working regularly away from the home. They should be taken at about the time the bowel tends to move, most often in the morning. The usual program is to instill 1 to 2 pints of slightly warmed tap water, allow it to return, and repeat until the returns are clear. Time must be allowed for the return of all of the irrigating fluid. The entire process may require an hour or even longer. Many rather elaborate and often expensive irrigating appliances have been developed; none are clearly superior to the usual enema can or bag. The hard tip suitable for rectal enemas is replaced by a large catheter which is inserted some 15 to 20 cm. into the stoma. Some provision must be made to catch and dispose of the washings. Most patients have little difficulty in devising suitable methods. The stoma is kept moist constantly by the secretion of mucus. Some type of belt, the less complex the better, is used to keep a small pad of absorbent paper in place over the stoma. The dressing is covered by a sheet of plastic to protect the belt. A two-way stretch girdle is probably the best appliance for both men and women, although more complex socalled colostomy belts have been devised. Drugs have little place in the management of colonic stomas. Well-
Problems Following Colostomy and Ileostomy
995
adjusted, intelligent persons may be allowed paregoric or anticholinergic medicaments to control occasional attacks of mild diarrhea, but they should be cautioned carefully against their regular use. Constipation and excessive firmness of stools should be managed by increasing the intake of food and fluids, not by recourse to physics. Satisfactory regulation of a stoma practically never can be achieved if the patient persists in the use of laxatives-which, it might be added, is a fairly common problem. Very likely if the patient is elderly or has mismanaged the bowels for years, the stools cannot be controlled as indicated. A colostomy bag then becomes necessary. The most satisfactory types are disposable bags or or non-disposable bags made entirely of plastic and metal. Rubber bags, which invariably become odorous, should not be used. Temporary Colonic Stomas
Temporary colonic stomas become necessary fairly often to relieve colonic obstruction, to protect an anastomosis, or to shunt the fecal stream away from a perforating inflammatory process such as complicated diverticulitis or extensive perianal abscess and fistula. A loop of the colon is simply brought out beyond the skin. If the transverse colon is used the stool tends to be liquid, or, at best, semi-formed; with a sigmoidal stoma the stool may be well formed. Continuity of the bowel usually will be restored before the patient has had sufficient time to learn to manage the colostomy. Voluminous dressings are employed to contain the discharges. Absorbent paper is preferable to gauze or cloth for dressings because it is less irritating and more readily disposable. A colostomy bag may be used, but the size and type of stoma make fitting of the appliance difficult. Disposable bags are preferable and rubber appliances are the least desirable. Cutaneous irritation of some degree usually develops. Ointments, sprays, and protective dressings are in general less effective than keeping the skin surrounding the stoma dry by changing dressings frequently and by exposing the region to the air. ILEAL STOMAS
The same surgical complications that occur after colostomy occur after ileostomy. In general, they develop more frequently, are more serious, and are more diffieult to treat. Additionally, the problems of fluid and electrolyte loss, cutaneous irritation, and obstruction of the small bowel may arise. Sloughing and Fistula
The ileum is poorly adapted to being brought through the abdominal wall, and a segment of ileum as long as 6 to 7 cm. with a narrow margin of mesentery must be extended beyond the skin. Unfortunately, slough-
996
R.
MAHDEN
BLACK
ing is fairly common. If the necrosis extends backward to below the skin, a new stoma must be formed promptly. Attempts may be made to preserve the stoma by minor plastic procedures if the necrosis is limited to the end of the bowel, or to the turned-back bowel if the stoma is of the Brooke type. Fistulas arising from the segment of bowel passing through the abdominal wall usually require the formation of another stoma. Sutures are never placed between the wall of the bowel and the abdominal wall, since they may cause fistulas. Fistulas develop most commonly during the period immediately after the formation of the stoma, presumably from erosion of the wall of the bowel by structures in the abdominal wall, particularly the cut edges of the fascia. They may develop even years later, however, most often from pressure of the appliance on the undersurfaee of the protruding bowel.
Fluid and Electrolyte Problems Usually the losses of fluids and electrolytes are greatest immediately after the formation of the stoma. After complete healing and after subsidence of all edema-or, to use the term commonly employed, after the stoma has matured-the losses are materially less. The concentrations of sodium and potassium in ileal excretions soon after formation of the stoma were reported by Fowler and his colleagues to be respectively 135 and 20 mEq. per kilogram of excreta. The losses from matured stomas were found to be only 20 to 70 mEq. of sodium and 10 mEq. of potassium each day. The loss of sodium in the urine was decreased when the loss from the stoma was high; by contrast, the loss of potassium remained high, both in the urine and from the stoma. To replace the losses, provision of 70 mEq. of potassium each day was advised. The losses of chlorides were variable, and unless the patient was vomiting the balance was likely to be positive. The excretion from a recently formed ileal stoma is usually not greater than 1500 ml. each day. With time, the excretions gradually thicken and decrease in amount until, from matured stomas, the amount of excretion usually is between 500 and 1000 ml. a day, depending somewhat on diet and intake of fluids. DYSFUNCTION OF ILEAL STOMA. The replacement of losses of fluids and electrolytes of the magnitudes mentioned previously presents no problems. Occasionally the losses are materially greater, and several liters may be passed each day. The outpouring of fluid starts soon after the stoma begins to function and may continue for days. The condition, known as "ileostomy dysfunction," results from partial obstruction of the small bowel. The site of obstruction is almost invariably in the short segment of bowel protruding beyond the abdominal wall. The development of such dysfunction is uncommon after formation of either skingrafted or Brooke-type stomas, and if it does occur it is usually mild and
Problems Following Colostomy and Ileostomy
997
transient. If severe dysfunction develops, reestablishment of the stoma should be considered before the condition of the patient becomes critical. Minor bouts of partial obstruction causing mild cramping and an increase or a decrease in the excretions from the ileal stoma may occur from time to time after the stoma has become mature. They are usually brought on by some change in the dietary or in the intake of fluids. Patients learn to avoid the attacks by not varying the intake of food and fluids, and by keeping some watch on the consistency and amount of the ileal excretions. When they become too thick or the amount decreases, the intake of fluids should be increased promptly. The best immediate treatment for the fully developed attack is the passage of a large soft catheter into the stoma for a distance of perhaps 15 cm. There should be an immediate discharge of fluid and usually of gas. The catheter is left in place for 15 or 20 minutes. Intubation of the stoma may be repeated as necessary. Although there is some risk of causing a fistula, most patients with an ileal stoma should be provided with a catheter and instructed in its use, since early relief of such functional obstructions is usually possible, whereas the maneuver often fails after the obstruction has existed for even a few hours. Should the obstruction persist and worsen, the usual treatment for an acute obstruction of the small bowel should be instituted. The patient should be admitted to the hospital, a long tube of the Miller-Abbott type should be started, and the deficit of fluids and electrolytes should be made up as rapidly as possible. Volvulus of the terminal ileum, adhesive obstructions, and internal herniations all may occur. The possibility that an acute surgical emergency has developed should be given early serious consideration unless the obstruction is relieved promptly by the long tube. Cutaneous Irritation
The problem of major cutaneous irritation resulting from the discharge of ileal excretions on the abdominal wall has almost been solved by the newer kinds of stoma and more modern appliances. A temporary appliance is emplaced at operation, and the appliance to be worn permanently is fitted before the patient leaves the hospital. Ileal excretions are thus prevented from coming in contact with the skin. If because of shortness, sloughing, or fistulas the excretions cannot be kept from the skin, the formation of a new stoma may become necessary. Lesser degrees of cutaneous irritation are extremely common. Some leakage around the appliance occurs occasionally, regardless of the type of bag. With use of glue-on bags, local sensitivity may develop to the adhesive or the material of which the bag is constructed. In hot weather, particularly, sweating beneath the appliance may cause irritation. Difficulties with the skin are most common during the first few weeks and result most often from improper fitting of the appliance. As the patient
998
R.
MARDEN BLACK
learns to manage the bag and as the secretions thicken, the skin tends to improve. Keeping the skin as dry as possible and the use of powdered sterculia (karaya) gum are probably as effective as any measures in controlling the irritation. Rarely is the cutaneous reaction to glue-on bags severe enough to require a change in the type of appliance. Prolapse of the Stoma
Perhaps the chief disadvantage of the Brooke-type stoma is the tendency for the bowel to prolapse. When the prolapse is progressive and the protruding bowel becomes too long, a new stoma becomes necessary. Regardless of the size or appearance of the prolapsed bowel, the stoma should not be sacrificed so long as it functions satisfactorily. Shortening of the prolapsed stoma by amputating part of the protruding bowel usually fails completely or proves of temporary benefit only. Skin-grafted stomas longer than approximately 5 cm. do not prolapse; in this respect they are clearly superior to stomas of the Brooke type. Grafting of the stoma has proved the only certain method of preventing prolapse. Grafting should be strongly considered in cases of prolapse requiring surgical treatment and especially in cases of repeated prolapse of a mucosa-covered stoma. Prolapse may be associated with the formation of a hernia. Surprisingly, in view of the frequency of herniation at the site of colonic stomas, this complication occurs rarely and usually is not a major problem with ileal stomas. Retraction and Stenosis
Although far less common than prolapse, retraction and stenosis also may occur with Brooke-type stomas. One of the problems in fashioning a Brooke-type stoma is that the end of the bowel does not remain turned back over the protruding bowel. When the turn-back fails, the end of the ileum is left flush with skin and excretions are passed out upon the abdominal wall. Another stoma usually must be established either immediately or later when stenosis develops. The principal disadvantage of skin-grafted stomas is the development of stenosis in the segment of bowel covered by the graft. Probably because of a chronic inflammatory process caused by the constant moisture in the bag, the skin thickens and contracts, ultimately producing obstruction. When this occurs the stoma must be sacrificed. With grafted stomas glue-on bags, which are essentially airtight, are less satisfactory than appliances which permit some circulation of air. Conversely, with Brooke-type stomas glue-on bags are more satisfactory in that leakage is less likely to occur. Psychologic Problems
Some mention should be made of the psychologic problems associated with ileostomy. Whatever the indications one accepts for the surgical
Problems Following Colostomy and Ileostomy
999
treatment of ulcerative colitis, the symptoms should have had sufficient severity and duration to make an ileostomy more acceptable than the disease. In spite of the many complications that may occur, the great majority of patients make a satisfactory adjustment to their stomas in time and become fully rehabilitated. The most difficult period of adjustment is during the early postoperative months, when the patient is attempting to learn to manage the stoma and to find a satisfactory appliance. Membership in clubs or associations of people with ileal stomas such as the "QT" clubs or "Ileoptomists" is helpful. If no formal organizations exist locally, discussions with patients who have succeeded in adjusting to ileal stomas are useful. A sympathetic nurse with a knowledge of the problems faced by a patient and the appliances available is almost a necessity in any institution in which ileostomy is performed. REFERENCE 1. Fowler, D. 1., Cooke, W. T., Brooke, B. N., and Cox, E. V.: Ileostomy and Elec-
tolyte Excretion. Am. J. Digest. Dis. n.s. 4: 710-720 (Sept.) 1959.
COLONIC STOMA
Complications
The complications occurring immediately after the formation of a colonic stoma include infarction and sloughing of the end of the colon, prolapse of a loop of small bowel beside the colon, formation of fistulas, and retraction of the end of the colon. Major surgical complications arc unusual and should be preventable; when they do occur, however, immediate surgical treatment is necessary. Extensive sloughing of the end of the colon is particularly unfortunate, since usually a new and far less satisfactory loop colonic stoma must be established. Subcutaneous infections at the site of the stoma are rather common. Ordinarily healing occurs, with time, unless a fistula develops. Practically the only complications of a long-established colonic stoma are prolapse of the bowel, stricturing at the junction of skin and mucosa, and formation of hernias at the site of the stoma. The three complications tend to occur together. The opening in the skin becomes progressively smaller until the bowel cannot empty satisfactorily, the bowel beyond the fasciallayer elongates, and a hernia-which can be large or small-develops. The complications arc not preventable and recurrences eventuate also, though usually only after many months or years. Ultimately, surgical treatment may become necessary, but it is relatively simple. In the procedure of "plastic enlargement of the stoma" or "revision of the colostomy," the opening in the skin is enlarged, the redundant bowel is excised, the hernial sac is removed, and the peritoneum is reclosed snugly around the bowel. Although the surgical procedure presents no problems, infection of the surrounding tissues develops commonly, often requiring a hospital stay out of all proportion to the magnitude of the procedure. Slight bleeding from the exposed mucosa resulting from irritation by the dressings is not uncommon. The bleeding usually stops promptly after a change in the type of dressings or in the tightness of the belt. The possibility of a carcinoma or a polyp should be considered if the
993
994
R.
MARDEN BLACK
bleeding does not stop, or if it seems to originate above the exposed mucosa. Routine Management
The management of a permanent colonic stoma is quite simple in principle. The purpose of the program is to achieve a firm, formed stool that is evacuated at the same time each day. To this end, foods that have a laxative effect such as fruits and vegetables are eaten moderately and excessive intake of fluid is avoided. To provide the desired regularity, the intake of food and fluids is kept as constant as possible in both time and amount. As a rule the establishment of a suitable routine requires several months. Some regularity should begin to appear within a few weeks; and at about the same time, the stools should begin to become formed. Continued looseness of the bowels results most commonly from an excessive intake of liquids, and less often from excessive amounts of fruits and vegetables. Occasional looseness usually may be traced easily to some obvious change in the dietary. When firmness of the stool has been achieved, some experimentation with different foods and with the amounts of food should be encouraged. The common tendency, particularly of elderly persons, to limit the diet unduly should be guarded against. I prefer not to begin irrigations until after some control has been achieved by dietary measures alone. Irrigations are something of a nuisance; and many persons who are able to remain at home, such as housewives and retired individuals, may be able to manage without their use. Irrigations are usually advisable in the case of persons working regularly away from the home. They should be taken at about the time the bowel tends to move, most often in the morning. The usual program is to instill 1 to 2 pints of slightly warmed tap water, allow it to return, and repeat until the returns are clear. Time must be allowed for the return of all of the irrigating fluid. The entire process may require an hour or even longer. Many rather elaborate and often expensive irrigating appliances have been developed; none are clearly superior to the usual enema can or bag. The hard tip suitable for rectal enemas is replaced by a large catheter which is inserted some 15 to 20 cm. into the stoma. Some provision must be made to catch and dispose of the washings. Most patients have little difficulty in devising suitable methods. The stoma is kept moist constantly by the secretion of mucus. Some type of belt, the less complex the better, is used to keep a small pad of absorbent paper in place over the stoma. The dressing is covered by a sheet of plastic to protect the belt. A two-way stretch girdle is probably the best appliance for both men and women, although more complex socalled colostomy belts have been devised. Drugs have little place in the management of colonic stomas. Well-
Problems Following Colostomy and Ileostomy
995
adjusted, intelligent persons may be allowed paregoric or anticholinergic medicaments to control occasional attacks of mild diarrhea, but they should be cautioned carefully against their regular use. Constipation and excessive firmness of stools should be managed by increasing the intake of food and fluids, not by recourse to physics. Satisfactory regulation of a stoma practically never can be achieved if the patient persists in the use of laxatives-which, it might be added, is a fairly common problem. Very likely if the patient is elderly or has mismanaged the bowels for years, the stools cannot be controlled as indicated. A colostomy bag then becomes necessary. The most satisfactory types are disposable bags or or non-disposable bags made entirely of plastic and metal. Rubber bags, which invariably become odorous, should not be used. Temporary Colonic Stomas
Temporary colonic stomas become necessary fairly often to relieve colonic obstruction, to protect an anastomosis, or to shunt the fecal stream away from a perforating inflammatory process such as complicated diverticulitis or extensive perianal abscess and fistula. A loop of the colon is simply brought out beyond the skin. If the transverse colon is used the stool tends to be liquid, or, at best, semi-formed; with a sigmoidal stoma the stool may be well formed. Continuity of the bowel usually will be restored before the patient has had sufficient time to learn to manage the colostomy. Voluminous dressings are employed to contain the discharges. Absorbent paper is preferable to gauze or cloth for dressings because it is less irritating and more readily disposable. A colostomy bag may be used, but the size and type of stoma make fitting of the appliance difficult. Disposable bags are preferable and rubber appliances are the least desirable. Cutaneous irritation of some degree usually develops. Ointments, sprays, and protective dressings are in general less effective than keeping the skin surrounding the stoma dry by changing dressings frequently and by exposing the region to the air. ILEAL STOMAS
The same surgical complications that occur after colostomy occur after ileostomy. In general, they develop more frequently, are more serious, and are more diffieult to treat. Additionally, the problems of fluid and electrolyte loss, cutaneous irritation, and obstruction of the small bowel may arise. Sloughing and Fistula
The ileum is poorly adapted to being brought through the abdominal wall, and a segment of ileum as long as 6 to 7 cm. with a narrow margin of mesentery must be extended beyond the skin. Unfortunately, slough-
996
R.
MAHDEN
BLACK
ing is fairly common. If the necrosis extends backward to below the skin, a new stoma must be formed promptly. Attempts may be made to preserve the stoma by minor plastic procedures if the necrosis is limited to the end of the bowel, or to the turned-back bowel if the stoma is of the Brooke type. Fistulas arising from the segment of bowel passing through the abdominal wall usually require the formation of another stoma. Sutures are never placed between the wall of the bowel and the abdominal wall, since they may cause fistulas. Fistulas develop most commonly during the period immediately after the formation of the stoma, presumably from erosion of the wall of the bowel by structures in the abdominal wall, particularly the cut edges of the fascia. They may develop even years later, however, most often from pressure of the appliance on the undersurfaee of the protruding bowel.
Fluid and Electrolyte Problems Usually the losses of fluids and electrolytes are greatest immediately after the formation of the stoma. After complete healing and after subsidence of all edema-or, to use the term commonly employed, after the stoma has matured-the losses are materially less. The concentrations of sodium and potassium in ileal excretions soon after formation of the stoma were reported by Fowler and his colleagues to be respectively 135 and 20 mEq. per kilogram of excreta. The losses from matured stomas were found to be only 20 to 70 mEq. of sodium and 10 mEq. of potassium each day. The loss of sodium in the urine was decreased when the loss from the stoma was high; by contrast, the loss of potassium remained high, both in the urine and from the stoma. To replace the losses, provision of 70 mEq. of potassium each day was advised. The losses of chlorides were variable, and unless the patient was vomiting the balance was likely to be positive. The excretion from a recently formed ileal stoma is usually not greater than 1500 ml. each day. With time, the excretions gradually thicken and decrease in amount until, from matured stomas, the amount of excretion usually is between 500 and 1000 ml. a day, depending somewhat on diet and intake of fluids. DYSFUNCTION OF ILEAL STOMA. The replacement of losses of fluids and electrolytes of the magnitudes mentioned previously presents no problems. Occasionally the losses are materially greater, and several liters may be passed each day. The outpouring of fluid starts soon after the stoma begins to function and may continue for days. The condition, known as "ileostomy dysfunction," results from partial obstruction of the small bowel. The site of obstruction is almost invariably in the short segment of bowel protruding beyond the abdominal wall. The development of such dysfunction is uncommon after formation of either skingrafted or Brooke-type stomas, and if it does occur it is usually mild and
Problems Following Colostomy and Ileostomy
997
transient. If severe dysfunction develops, reestablishment of the stoma should be considered before the condition of the patient becomes critical. Minor bouts of partial obstruction causing mild cramping and an increase or a decrease in the excretions from the ileal stoma may occur from time to time after the stoma has become mature. They are usually brought on by some change in the dietary or in the intake of fluids. Patients learn to avoid the attacks by not varying the intake of food and fluids, and by keeping some watch on the consistency and amount of the ileal excretions. When they become too thick or the amount decreases, the intake of fluids should be increased promptly. The best immediate treatment for the fully developed attack is the passage of a large soft catheter into the stoma for a distance of perhaps 15 cm. There should be an immediate discharge of fluid and usually of gas. The catheter is left in place for 15 or 20 minutes. Intubation of the stoma may be repeated as necessary. Although there is some risk of causing a fistula, most patients with an ileal stoma should be provided with a catheter and instructed in its use, since early relief of such functional obstructions is usually possible, whereas the maneuver often fails after the obstruction has existed for even a few hours. Should the obstruction persist and worsen, the usual treatment for an acute obstruction of the small bowel should be instituted. The patient should be admitted to the hospital, a long tube of the Miller-Abbott type should be started, and the deficit of fluids and electrolytes should be made up as rapidly as possible. Volvulus of the terminal ileum, adhesive obstructions, and internal herniations all may occur. The possibility that an acute surgical emergency has developed should be given early serious consideration unless the obstruction is relieved promptly by the long tube. Cutaneous Irritation
The problem of major cutaneous irritation resulting from the discharge of ileal excretions on the abdominal wall has almost been solved by the newer kinds of stoma and more modern appliances. A temporary appliance is emplaced at operation, and the appliance to be worn permanently is fitted before the patient leaves the hospital. Ileal excretions are thus prevented from coming in contact with the skin. If because of shortness, sloughing, or fistulas the excretions cannot be kept from the skin, the formation of a new stoma may become necessary. Lesser degrees of cutaneous irritation are extremely common. Some leakage around the appliance occurs occasionally, regardless of the type of bag. With use of glue-on bags, local sensitivity may develop to the adhesive or the material of which the bag is constructed. In hot weather, particularly, sweating beneath the appliance may cause irritation. Difficulties with the skin are most common during the first few weeks and result most often from improper fitting of the appliance. As the patient
998
R.
MARDEN BLACK
learns to manage the bag and as the secretions thicken, the skin tends to improve. Keeping the skin as dry as possible and the use of powdered sterculia (karaya) gum are probably as effective as any measures in controlling the irritation. Rarely is the cutaneous reaction to glue-on bags severe enough to require a change in the type of appliance. Prolapse of the Stoma
Perhaps the chief disadvantage of the Brooke-type stoma is the tendency for the bowel to prolapse. When the prolapse is progressive and the protruding bowel becomes too long, a new stoma becomes necessary. Regardless of the size or appearance of the prolapsed bowel, the stoma should not be sacrificed so long as it functions satisfactorily. Shortening of the prolapsed stoma by amputating part of the protruding bowel usually fails completely or proves of temporary benefit only. Skin-grafted stomas longer than approximately 5 cm. do not prolapse; in this respect they are clearly superior to stomas of the Brooke type. Grafting of the stoma has proved the only certain method of preventing prolapse. Grafting should be strongly considered in cases of prolapse requiring surgical treatment and especially in cases of repeated prolapse of a mucosa-covered stoma. Prolapse may be associated with the formation of a hernia. Surprisingly, in view of the frequency of herniation at the site of colonic stomas, this complication occurs rarely and usually is not a major problem with ileal stomas. Retraction and Stenosis
Although far less common than prolapse, retraction and stenosis also may occur with Brooke-type stomas. One of the problems in fashioning a Brooke-type stoma is that the end of the bowel does not remain turned back over the protruding bowel. When the turn-back fails, the end of the ileum is left flush with skin and excretions are passed out upon the abdominal wall. Another stoma usually must be established either immediately or later when stenosis develops. The principal disadvantage of skin-grafted stomas is the development of stenosis in the segment of bowel covered by the graft. Probably because of a chronic inflammatory process caused by the constant moisture in the bag, the skin thickens and contracts, ultimately producing obstruction. When this occurs the stoma must be sacrificed. With grafted stomas glue-on bags, which are essentially airtight, are less satisfactory than appliances which permit some circulation of air. Conversely, with Brooke-type stomas glue-on bags are more satisfactory in that leakage is less likely to occur. Psychologic Problems
Some mention should be made of the psychologic problems associated with ileostomy. Whatever the indications one accepts for the surgical
Problems Following Colostomy and Ileostomy
999
treatment of ulcerative colitis, the symptoms should have had sufficient severity and duration to make an ileostomy more acceptable than the disease. In spite of the many complications that may occur, the great majority of patients make a satisfactory adjustment to their stomas in time and become fully rehabilitated. The most difficult period of adjustment is during the early postoperative months, when the patient is attempting to learn to manage the stoma and to find a satisfactory appliance. Membership in clubs or associations of people with ileal stomas such as the "QT" clubs or "Ileoptomists" is helpful. If no formal organizations exist locally, discussions with patients who have succeeded in adjusting to ileal stomas are useful. A sympathetic nurse with a knowledge of the problems faced by a patient and the appliances available is almost a necessity in any institution in which ileostomy is performed. REFERENCE 1. Fowler, D. 1., Cooke, W. T., Brooke, B. N., and Cox, E. V.: Ileostomy and Elec-
tolyte Excretion. Am. J. Digest. Dis. n.s. 4: 710-720 (Sept.) 1959.